We were sitting around with friends and family recently over some very nice red wine when our friend Noel asked me about my weekly Toastmasters meetings, and specifically about whether I thought there are some people who simply never learn to feel comfortable speaking in public even after Toastmasters training. After a moment’s contemplation, I replied to Noel:
“I can’t really say – because those who actually feel too uncomfortable probably just stop attending after a while. The ones who stay seem pretty happy!”
It turns out that what I was describing is essentially what’s known as survivorship bias.*
This concept helps explain why you get happy longtime Toastmasters members like me (ever since 1987, when I was just a tiny baby) who are busy high-fiving our fellow club members over the fabulousness of an international program built on improving speaking, listening and thinking skills. Outside of our circle, however, there may indeed be many disgruntled ex-Toasties who don’t believe the program was at all useful for them.
But you’d never see that side, of course, if you sought out only people like me. That’s survivorship bias for you.
As described by the always intriguing David McRaney, author of the clever books You Are Not So Smart and his latest, You Are Now Less Dumb, survivorship bias refers to our tendency to focus on “survivors” instead of whatever you would call a non-survivor – like those lapsed Toastmasters members, for example, easily overlooked because of their current lack of visibility within the group.
Sometimes, as McRaney explains, this means we tend to focus on the living instead of the dead, or on winners instead of losers, or on successes instead of failures:
“It is easy to do. After any process that leaves behind survivors, the non-survivors are often removed from your view.
“If non-survivors become invisible, then naturally you will pay more attention to successes.
“Not only do you fail to recognize that what is missing might have held important information, you fail to recognize that there is missing information at all.”
My friends in the breast cancer community report a similar reality. During Breast Cancer Awareness Month, the holy month of Pinktober, when the corporate world is awash with pink awareness ribbons, every run/walk/bake sale/fundraiser “for the cure” celebrates with unabashed glee the pink-clad participants who have heroically “beaten” their cancer.
But at the same time, the world’s attention is self-consciously diverted away from those who are not there because they’re either no longer well enough or no longer alive.
One survivor recently wrote about publicity campaigns that focus on awareness and screening campaigns while ignoring those whose cancer treatment has not been successful:
“It is critical to recognize and respect the reality that the pink ribbon excludes the most important group of the breast cancer community – those with metastatic cancer.”
And as David McRaney warns:
“You must remind yourself that when you start to pick apart winners and losers, successes and failures, the living and dead, that by paying attention to one side of that equation, you are always neglecting the other.”
This preference for the positive can also support the false belief that those who succeed must clearly possess some uniquely superior qualities.
After author Barbara Ehrenreich was diagnosed with breast cancer, she described her own experience with this phenomenon in her essay in The Guardian called “Smile! You’ve Got Cancer”:
“The more fellow victims I discovered, the greater my sense of isolation grew.
“No one among the bloggers and book writers seemed to share my sense of outrage over the disease and the available treatments. What causes it and why is it so common, especially in industrialized societies? Why don’t we have treatments that distinguish between different forms of breast cancer, or between cancer cells and normal dividing cells?
“In the mainstream of breast cancer culture, there is very little anger, no mention of possible environmental causes, and few comments about the fact that, in all but the more advanced, metastasized cases, it is the ‘treatments’, not the disease, that cause the immediate illness and pain.
“In fact, the overall tone is almost universally upbeat.”
As best-selling Freakonomics authors Stephen Dubner and Steven Levitt remind us, another good example of survivorship bias is the stock market:
“Think of the Dow Jones Industrial Average, which indexes the stock prices of 30 of the largest and most important U.S. companies — until, that is, one of said companies does so poorly that it is booted from the index and is replaced by a company that’s doing better.
“Over time, therefore, the DJIA reflects a different reality than many people presume. It is biased toward survivors — or, if you want to think of the concept more broadly, toward winners.”
It’s also why colleges and conferences prefer hiring inspirational keynote speakers. Audiences love a winning example of struggle against tough odds. David McRaney adds:
“The problem here is that you rarely take away from these inspirational figures advice on what not to do, on what you should avoid, and that’s because they don’t know.
“Information like that is lost along with the people who don’t make it out of bad situations, or who don’t make it onto the cover of magazines – people who don’t get invited to speak at graduations and commencements and inaugurations.”
Or as Google Engineer Barnaby James warns:
“Beware advice from the successful.”
In the world of cardiovascular disease, a space I’ve become intimately familiar with since surviving a heart attack in 2008, we are duly inspired by stories of brave survivors who overcome all odds in order to thrive despite their cardiac catastrophe.
These are the guys who successfully complete their first marathon shortly after leaping off the O.R. gurney following lifesaving quadruple bypass surgery, which they of course sail through with nary a complication. These are the people whose terrifying cardiac events motivate them to quit smoking, drop 30 pounds, take up competitive swimming, become vegans and write a book about their heroic exploits with the evangelical zeal of a born-again health nut.
Survivors like this are so inspirational! Or are they? See also: Non-Inspirational Advice for Heart Patients.
When I first started my 3-month cardiac rehabilitation program, for example, I felt acutely dismayed – not inspired at all! – while listening to one of my fellow rehab buddies who boasted to me (and to everybody within earshot) that he was not only already back at work, but now golfing as well.
Back at work? Golfing? I could barely manage to somehow get myself down to the rehab gym twice a week, where I’d then have to hold onto the exercise bike for dear life. What was wrong with me? Why was I still experiencing these debilitating and ongoing cardiac symptoms, unable to return to work or go golfing?
Well, okay, I’m not a golfer, but you get my drift . . .
I’m guessing that when our cardiac rehab nurse is out telling her colleagues and funders about the program, she’s raving about that amazingly happy-working-golfing quadruple-bypass-surgery survivor, not about the middle-aged woman with distressing cardiac issues, still struggling just to keep up.
Supporters and donors want to hear about inspiring success stories of triumph over adversity.
And others who are somehow not able to bounce back as heroically get to feel guilty and embarrassed because they’re clearly “not doing it right”.
When I started writing about my own experience with debilitating post-heart attack depression on my Heart Sisters blog, I was gobsmacked by the immediate response from other heart attack survivors in the same boat. Even though, as Mayo Clinic experts tell us, up to 65% of survivors experience significant depression following a cardiac event, fewer than 10% are appropriately identified – and virtually nobody talks about it.
The trouble is, you can often miss a lot of reality when you’re gripped in the giddy throes of survivorship bias.
Final thoughts here from David McRaney, who sums up both the myth and the reality surrounding this concept:
The Misconception: You should focus on the successful if you wish to become successful.
The Truth: When failure becomes invisible, the difference between failure and success may also become invisible.
.
* I was duly inspired to ponder survivorship bias after reading this wonderful post on the Unqualified Self site.
See also:
The Ethical Nag 
Reblogged this on The Unquantified Self and commented:
“Great post on survivorship bias from the always spot-on Ethical Nag”
Thanks for reblogging this post – but especially thanks for introducing me to the term “survivorship bias” through your own writing!
Hi Carolyn!
You wrote: “But when I first started my 3-month cardiac rehabilitation program, (SNIP) Back at work? Golfing? I could barely manage to somehow get myself down to the rehab gym twice a week, where I’d then have to hold onto the exercise bike for dear life.”
Some patients, duly prescribed (“duly” according to misleading flawed, spun, some plain fraudulent studies) can’t exercise properly because of statins, add those who become impotent (ascribed to depression, stress, wimpiness, what else?)
About survivors: there are also false survivors, some of which wear a pink T shirt claiming “saved by screening”. Well er… sorry, maybe, and maybe not. When likely 1 in 3 of those cancers can’t be survived since they are not real cancers, as now proved by a clever Scandinavian study.
But it wouldn’t be humane nor nice to tell these women the truth. And anyway I think it is an unacceptable truth. Imagine “No you ain’t no survivor!” . There is a 30% chance you were overtreated for non-existent cancer, now deal with it !
No.
The problem is they participate in creating new overtreated patients. But the primary culprits are the key opinion leaders on breast cancer screening.
This is why breast cancer diagnoses increase, not breast cancer deaths. It’s not only that treatments are more effective. Surgery ± radiation ± chemo for a non cancer provides a cure for no disease and may create complications. In addition, it tags women with the bad name, often wrecks their morale and that of their loving ones, and cripples their insurance abilities. The problem is that there is no solution to this.
People prefer :
– their vested interests (selling fear, selling surgery, chemo, mammography machines etc.)
– not changing their minds or else they should admit they were wrong in the first place and have been acting wrongly
– getting an assertive answer that is scientifically plain wrong rather than an honest scientifically true answer that would be “we don’t f. know” what to do at this point, sorry.
Hello Pedrina and thanks for your comments. You bring up some weighty new issues – overdiagnosis and overtreatment, for example – that are worth blog posts in themselves.
Excellent post… thank you
You’re welcome, Mark…
Thank you for bringing up this ‘survivorship’ mind-set. I will post parts of it on a health forum with attribution. (It’s not a heart disease forum.) People there (moi) are castigated for presenting the raw facts and not a rose-tinted view of a disease where many stay debilitated despite their and their doctors’ best efforts.
I say the people who should be congratulated are those who slog on, day after day, some even managing to raise children while feeling like road kill. I got a real giggle out of your phrase “successfully complete their first marathon shortly after leaping off the O.R. gurney following lifesaving quadruple bypass surgery”
My first laugh of the day even though tinged ever so slightly with sadness, or is it outrage.
Thanks Cave – that inspiring CABGx4 marathoner is only a very slight exaggeration. 😉 You’re so right – the heroic “inspirations” get all the attention while the ‘real’ heroes are often those who may not ever be in the limelight (precisely because they feel like road kill…)
I love Barbara Ehrenreich’s work on the tyranny of positive thinking. The definition of “survivor” is fraught with assumptions and agendas, generally unspoken. To many, as I approach my 40th year post cancer diagnosis, I represent an unqualified success story. Woohoo! And for most people that is the end of it. Oncologists chalk up another success and send people back to their PCPs, and medical training neglects the effects of treatment.
I’m glad for every one of those bonus years (by now most of my life) but treatments (radical surgery, head and neck radiation, chemo) have guaranteed that I struggle every single day.
Long term radiation damage began to show up within a couple of years, but I didn’t recognize it, and my docs didn’t either. A dentist was the first, but he had no recommendations other than cosmetic work, and it was over 25 years before I learned that drugs that might help save my teeth had long been available.
For over 25 years docs have reacted with skepticism when I point out my history of radiation as a probable cause, but salivary damage, thyroid damage, brain tumor and inappropriate vasopressin production, even lung and cardiac damage, went undiagnosed and untreated for years, even decades, after they began causing me problems, damage and severe pain.
Last year I went to my very first cancer survivor conference. One speaker triumphantly detailed how he survived round after round of chemo and radiation, only to develop another cancer as a result of those treatments, yet there he was! Now bald from yet another course of radiation and chemo! Still fighting! And he was gong to beat it!!! The applauding crowd jumped to their feet. That’s what many seemed to come for, though I found it rather exhausting.
My husband’s unrelentingly positive thinking cousin died of metastasized breast cancer, and she is just as dead as his skeptical mother, who nonetheless always did exactly what her doctor recommended.
What I did learn at that conference (both from a speaker and in the hallway) is that most of my health problems are now entirely predictable consequences of my treatment.
With scientific and statistical training, I am better able than many to wade through medical articles and such, yet my suggestions and symptoms of health-threatening (even life-threatening) conditions were dismissed for years by my PCPs and a series of specialists.
I have been forced to wage a military-style campaign for appropriate diagnoses and treatment on many fronts. What about the ones who accept that they are “just a little off” or “must try harder” and slowly die of undiagnosed conditions?
Hello Kathleen and thanks so much for sharing your unique perspective. Barbara Ehrenreich might joke that, perhaps if you’d had a more POSITIVE ATTITUDE, you could have avoided 40 years of treatment-induced medical crises. 😉 Your many health problems may have been ‘predictable’ – but I wonder if are they getting any closer to becoming ‘preventable’?
We have a way of treating illness like warfare, so if you aren’t doing well with your illness, you are seen or see yourself as a poor fighter.
The point you make about missing information is huge.
Thank you Miep – those warfare medical metaphors are pervasive, aren’t they? Battling cancer, fighting bravely, winning the war on ___. More on this here.
Thanks, that’s good and the comments interesting as well. All this pressuring people to be upbeat is so alienating and misguided.
Being sick is a bad deal, why must we pressure people to act positive? I would think what a person wants to hear is “I am so, so sorry you’re having to deal with this” and then if you want to be supportive, offer to clean the person’s house or shop for her or otherwise identify stuff she really isn’t up to doing.
I hate to think of people being socially abandoned simply because their odds are bad though I expect it happens all the time.
“Offer to clean their house” – awesome! You are my kind of friend! One of the most helpful experiences ever while recuperating at home from my heart attack was when friends would phone and say things like: “I’m at the grocery store – what can I pick up for you while I’m here?” instead of saying “Just let me know if there’s anything I can do for you”. Trust me, I’m NEVER going to call anybody and ask them to come over and change the kitty litter… See also: “You Look Great!” And Other Things You Should Never Say To Heart Patients“
Socially abandoned? Oh, so very frequent, as healthy people don’t like to hear about “downers” and that creates yet another dilemma for the struggling.
I knew that my now-husband was the one when I got a horrible knock-you-out-for-3-weeks flu. That was when he came over with groceries, made me orange juice, all the while he cleaned my kitchen and started a pot of chicken soup.
Until then, I had thought he was a great guy, but not “my type.” I promptly reevaluated my type.
Oh, that guy’s a keeper, Kathleen . . . 🙂
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HI Carolyn— Truly glad you mentioned Pinktober and the rah-rah-rah cheerleading of “pink-clad survivors” as heroes. Its great they survived don’t get me wrong but that is only one small focus compared to those with metastatic breast cancer that Komen et al do NOT talk about — nothing cheerful about dying of BC mets — It’s a myth that screening is most important to survival—- there are at least 10 unique types of BC—- depends on which type a woman has— screening may help ID tumors may lead to overtreatment of tumors that will never be significant.
Helpful info here— very interesting. Thanx so much for this. — QSx2 in L.A.
Thanks for sharing your perspective here, QSx2.
I just wanted to take a moment to say that I really enjoy your blog(s). Many thanks.
Charlotte.
Thank you, Charlotte.
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